Templates › Inspections › SEO page

Run: Driving Rehabilitation Pre-Screen

Use this Driving Rehabilitation Pre-Screen template to document vision, reaction time, cognition, and physical function before deciding on a driver rehab eva...

Fill this out, get a PDF emailed to you. No account required. Want to run it with your team and track results? Sign up free →

Screening Instructions and Referral Basis

Referral source documented

Record who initiated the driving pre-screen (e.g., physician, therapist, family, self-referral, employer, insurer).

Physician order or authorized referral on file critical (required)

Confirm whether a physician order or other authorized referral is present when required by local policy or program protocol.

Yes No N/A

Primary concern for driving safety documented

Select the main concerns prompting the screen.

Note (optional)

Current driving status documented

Record the individual's current driving status.

Note (optional)

Vision Screening

Distance visual acuity recorded for each eye and both eyes critical (required)

Enter measured distance acuity values for right eye, left eye, and both eyes with correction status noted.

Visual field concern identified critical (required)

Indicate whether there is evidence of restricted visual field, neglect, hemianopsia, or other field loss affecting driving safety.

Yes No N/A

Depth perception and contrast sensitivity adequate for driving tasks

Assess whether the individual demonstrates functional depth perception and contrast awareness for lane position, curb detection, and hazard recognition.

Yes No N/A

Glasses or corrective lenses available and used as prescribed critical (required)

Confirm whether the individual arrived with the required corrective lenses and uses them consistently for driving.

Yes No N/A

Vision-related referral needed critical (required)

Select the recommended next step if visual screening is not sufficient for driving clearance.

Note (optional)

Reaction Time and Attention

Simple reaction time measured critical (required)

Record the measured reaction time from the screening task.

Note (optional)

Responds appropriately to visual and auditory cues critical (required)

Assess whether the individual can detect and respond to cues in a timely and consistent manner.

Yes No N/A

Divided attention during dual-task activity

Rate the individual's ability to maintain performance while managing a secondary task.

Reaction time concern requires further evaluation critical (required)

Choose the recommended next step based on screening findings.

Note (optional)

Cognition and Judgment

Orientation to person, place, time, and situation critical (required)

Rate orientation based on interview and screening observations.

Short-term memory adequate for driving-related instructions critical (required)

Determine whether the individual can recall and follow brief driving-related directions.

Yes No N/A

Judgment and insight into driving risk critical (required)

Rate the individual's awareness of limitations and ability to make safe driving decisions.

Cognitive screening result documented

Enter the name of the screening tool used and the score or summary result, if applicable.

Cognition-related referral needed critical (required)

Select the recommended next step based on cognitive screening findings.

Note (optional)

Physical Function and Mobility

Upper extremity range of motion supports steering and controls critical (required)

Assess whether shoulder, elbow, wrist, and hand motion appear sufficient for steering, signaling, and control use.

Yes No N/A

Lower extremity function supports pedal use critical (required)

Assess whether lower extremity strength, coordination, and range of motion support safe accelerator and brake use.

Yes No N/A

Transfers and seated posture adequate for vehicle operation

Determine whether the individual can maintain safe seated posture and perform vehicle transfers if needed.

Yes No N/A

Adaptive equipment or vehicle modification needed

Select whether adaptive equipment or vehicle modifications should be considered.

Note (optional)

Disposition, Findings, and Sign-Off

Screening disposition critical (required)

Select the final recommendation based on the pre-screen findings.

Note (optional)

Corrective action or follow-up plan documented critical (required)

Document any follow-up actions, referrals, restrictions, or education provided.

Inspector signature critical (required)

Signature of the clinician or evaluator completing the pre-screen.

Get your results

Enter your email — we'll send you a PDF of your filled-out template, plus the occasional MangoScoop newsletter (templates, workflow tips, product updates). Unsubscribe anytime — link is in every email.

Email (required)

Your name (optional)

Generated with MangoApps Templates — browse 250+ free